Hindawi Publishing Corporation Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 979213, 15 pages doi:10.1155/2012/979213

Review Article Cancer-Related Stress and Complementary and Alternative Medicine: A Review

Kavita D. Chandwani, Julie L. Ryan, Luke J. Peppone, Michelle M. Janelsins, Lisa K. Sprod, Katie Devine, Lara Trevino, Jennifer Gewandter, Gary R. Morrow, and Karen M. Mustian

James P. Wilmot Cancer Center, Department of Radiation Oncology, School of Medicine and Dentistry, University of Rochester Medical Center, Saunders Research Building, 265 Crittenden Boulevard, Office 2.224, Box CU 420658, Rochester, NY 14642, USA

Correspondence should be addressed to Kavita D. Chandwani, kavita [email protected]

Received 2 January 2012; Accepted 1 June 2012

Academic Editor: Alyson Huntley

Copyright © 2012 Kavita D. Chandwani et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A cancer diagnosis elicits strong psychophysiological reactions that characterize stress. Stress is experienced by all patients but is usually not discussed during patient-healthcare professional interaction; thus underdiagnosed, very few are referred to support services. The prevalence of CAM use in patients with history of cancer is growing. The purpose of the paper is to review the aspects of cancer-related stress and interventions of commonly used complementary and alternative techniques/products for amelioration of cancer-related stress. Feasibility of intervention of several CAM techniques and products commonly used by cancer patients and survivors has been established in some cancer populations. Efficacy of some CAM techniques and products in reducing stress has been documented as well as stress-related symptoms in patients with cancer such as mindfulness-based stress reduction, yoga, Tai Chi Chuan, acupuncture, energy-based techniques, and physical activity. Much of the research limitations include small study samples and variety of intervention length and content. Efficacy and safety of many CAM techniques and some herbs and vitamin B and D supplements need to be confirmed in further studies using scientific methodology. Several complementary and alternative medicine therapies could be integrated into standard cancer care to ameliorate cancer-related stress.

1. Introduction and indicate distress [11]. Regardless of treatment regi- men, distressing symptoms such as fatigue, insomnia, pain, Cancer-related distress is defined as an “unpleasant emo- depression, hot flashes, sexual dysfunction, and cognitive tional experience of a psychological, social, and/or spiritual ff deficits frequently occur and often persist following treat- nature that may interfere with the ability to cope e ectively ment [12, 13]. Overall, a cancer diagnosis creates a vicious with cancer, its physical symptoms, and its treatment” [1]. and compounding cycle of stress. Several factors can cause stress during the cancer experience; Although all patients with a history of cancer experience a cancer diagnosis itself is a strong stressor associated with variable level of stress across the continuum of disease [1], “disbelief, anxiety, depression,” and disturbances of sleep, appetite, and routine daily activities [2]. In addition to often information sharing on this topic does not happen dur- uncertainty about the disease and its treatment, there is ing interaction of patients with their healthcare professionals also fear of death, disease progression, reduction in quality [1]. The reported prevalence of cancer-related distress is of life (QOL) and relationships, a loss of sense of control 24–59% depending on the type of cancer [10], stage of dis- [3–10], and impacts on decision-making ability and treat- ease, patient population studied, and study setting [14, 15]. ment compliance [1]. Cancer patients experience a broad A recent study of newly diagnosed cases reported distress in spectrum of individual and cooccurring symptoms such about 67% of lung cancer patients and 50% of breast cancer as pain, anxiety, depression, fatigue, nausea, diarrhea, patients [16]. Another study found self-reported distress in wasting, and cognitive impairments, which both promote 25% of cancer outpatients, 59% of patients with advanced 2 Evidence-Based Complementary and Alternative Medicine cancer undergoing palliative care, and 16% of cancer patients controls [32, 33], which is associated with shorter survival in the general community [14]. Psychosocial interventions times [33]. including experiential-existential group psychotherapy and Stressful events like cancer have been shown to lead cognitive-behavioral stress management [17–22] have shown to increased risk of disease progression and decreased positive results in coping with daily stressors. Additionally, survival [34–37], and they can contribute to dysregulation of pharmacologic treatments for some of the cancer-related the immune system, chronic inflammation, and numerous psychiatric symptoms are available. Some resources are adverse effects [38]. Psychological stress and altered HPA available in the form of information on its identification axis function can influence the activity of a variety of and possible counseling services recommended by various immune cells, including natural killer (NK) cells, T cells, national societies and institutions [1]. However, only a and macrophages [39]. Disrupting the balance of immune small percentage of patients with distress are detected and cells leads to a chronic proinflammatory cytokine-mediated referred for treatment [1]. The use of complementary and cascade of events resulting in enhanced psychological stress, alternative medicine (CAM) has increased among cancer depression, anxiety, fatigue, sleep disturbance, cognitive patients at the time of diagnosis, during treatment, and impairments, and ultimately reduced quality of life [40–44]. even after treatment is complete [23]. The primary reasons Stress hormones can impair the immune response and may for CAM use by cancer patients are pain relief, immune- affect tumor progression and cancer prognosis. Chronically system boost, symptom management [24], and better quality elevated stress hormones shift the balance between the Th1 of life [25]. However, there are concerns about the use (cellular) and Th2 (humoral) immune responses toward the of CAM techniques related to cancer experience since the Th2 response. Expression of Th1 cytokines IFN-γ and IL- efficacy of several of these techniques/products has not 12 decreases during stress, while Th2 cytokines IL-4, IL- been documented or due to possibility of interaction with 5, IL-6, IL-10, and IL-13 increase (reviewed in [45, 46]). treatment. This paper reviews aspects of cancer-related stress These changes are associated with decreased cytotoxic T- and CAM interventions for the amelioration of stress during lymphocyte and natural killer (NK) cell activity [47, 48]. and after the cancer experience. Researchers over time have Evidence from animal models suggests that these types used the words “stress” and “distress” interchangeably, and in of immune deficiencies can lead to tumor progression. this paper, the term “stress” will be used unless the referenced For example, mice subjected to social isolation stress had study used the word “distress”. decreased splenic NK cell activity [49]. In the same mice, metastasis required less time after tumor cell injection in stressed animals than in controls. Stressed animals also did 2. Neuroendocrine and Immunological not respond as well to chemotherapy [50]. Aspects of Stress and Cancer Stress hormones can also alter cell-signaling pathways, which have been implicated in cancer progression. Many Stress is characterized by psychophysiological processes studies suggest that stress hormones can decrease apoptosis in response to an event or circumstance that is per- in certain cancer cells through decreased activity of pro- ceived as threatening, harmful, or challenging [26]. The apoptotic caspases-3, 8, and 9 [51] and protein BAD [52]. hypothalamus-pituitary-adrenal (HPA) axis and the sym- Increases in vascular endothelial growth factor (VEGF), pathetic nervous system (SNS) are involved in the physical which is important for tumor vascularization and survival stress response. The HPA axis functions through a negative [53], have been shown in cancer cell culture models as a feedback system: increased cortisol and other glucocorti- result of norepinephrine-dependent β-adrenoreceptor acti- coid (GC) levels inhibit release of corticotrophin-releasing vation of the cAMP/PKA signaling pathway [54–56], and this hormone (CRH) and adrenocorticotropic hormone (ACTH) could be critical in tumor progression. In an animal model of from the neurons of the hypothalamus and pituitary gland, ovarian cancer, psychological stress simultaneously increased respectively, leading to a reduction in GC levels (Figure 1(a)). VEGF expression and tumor burden [57]. A chronic or repeated exposure to a stressor decreases CRH, Metastasis relies on tumor cell invasion, which requires ACTH, and GC levels [27, 28] indicating a reduction in proteins that can break down the extracellular matrices of negative feedback in the HPA axis. In cancer patients, such the invaded tissues; preliminary evidence of the same is dysregulation of the HPA axis and the SNS may be related provided by norepinephrine-stimulated ovarian cell invasion to the development, maintenance, and recurrence of cancer. and increased matrix-metalloproteinase- (MMP-)2 and 9 For instance, norepinephrine has been linked to the etiology expression through activation of the β-adrenergic receptor of cancer [29], and epinephrine has been shown to protect [58] and an increase in MMP-2 and 9 associated with against cellular apoptosis in cancer cells [30]. In women with psychological stress in the ovarian cancer mouse model metastatic breast cancer, HPA axis dysregulation was char- [57]. Thus, it is conceivable that stress management might acterized by increased resting cortisol levels (Figure 1(b)) reduce disease progression and improve quality of life in and decreased inhibition of the pituitary gland and the patients with cancer. We note that while this is a plausible hypothalamus [31]. Although a linear relationship between hypothesis, the evidence supporting it in cancer patients is resting cortisol levels and stage of cancer was observed, lacking. Several modalities for stress reduction have shown ACTH levels were normal in both early and late stages [31]. promise; use of other options can be considered based on Other studies have shown that some cancer patients have evidence provided by recent research on complementary and a flattened diurnal cortisol rhythm compared to healthy alternative medicine (CAM) techniques/products. Evidence-Based Complementary and Alternative Medicine 3

Hypothalamus CRH CRH

Pituitary ACTH ACTH gland

Adrenal ↑Cortisol gland Cortisol (a) Normal HPA-axis regu- (b) Proposed lation HPA-axis dysregulation for high cortisol levels Figure 1: Overview of the hypothalamus-pituitary-adrenal axis in relation to the stress response in healthy individuals (a) and those with cancer (b). CRH: corticotrophin-releasing hormone; ACTH: adrenocorticotropic hormone. Thin dashed lines represent reduced feedback inhibition.

3. Complementary and Alternative Medicine (MBSR). MBM is increasingly used by breast cancer patients Utilization in Cancer [71]. A recent study reported that 64.2% of breast cancer patients practiced mind-body techniques following their CAM has been defined by the National Center for Comple- diagnosis, and this usage was associated with Hispanic race, mentary and Alternative Medicine (NCCAM) as “a group higher education, low income, and other CAM use [72]. of diverse medical and health care systems, practices, and Research on MBM in cancer has grown in the past decade, products that are not generally considered part of con- although the majority of studies have been conducted in ventional medicine” [59]. Such techniques include mind- the breast cancer population. Moreover, studies have used a body medicine, natural products, nutritional supplemen- variety of designs, intervention programs, and measures to tation, manipulative body-based practices, energy-based evaluate effects, and most of the research has involved small techniques, and traditional medical systems (e.g. Chinese, sample sizes. Larger studies are needed to confirm the effects Ayurved, and American-Indian). These modalities have of many mind-body techniques on common symptoms of recently been classified as integrative medicine as they are cancer and its treatment. not an alternative to conventional medicine use; however, for Several studies in cancer patients have examined the the purpose of this paper the term CAM will be employed. effect of meditation and yoga on quality of life, fatigue, and CAM use has been increasing among cancer patients [23] sleep [73–80]. Mindfulness-based stress reduction (MBSR), and currently ranges from 22% to 73% [60]. Based on 2002 a program that includes meditation, yoga postures, and National Health Interview data, 26% of female survivors relaxation [81], helps patients understand their personal and 13.7% of male cancer survivors reported using CAM responses to stress and teaches them how to modify their [61]. A more recent study revealed that 62% of female responses. A program of MBSR reported lower levels of total breast cancer survivors used CAM [62]. CAM use in cancer mood disturbance and distress [82] as well as significant patients is associated with high levels of distress and failure improvements in mood, sleep quality, and fatigue in a of conventional medicine to meet psychosocial needs [63]. mixed cancer population [83]. Other studies using MBSR Although emotional distress along with other psychological interventions in cancer patients have shown decreases in indices significantly predicted CAM use in male and female stress symptoms and cortisol levels and improvements in survivors of colon cancer [64], a study of predictors of patient-reported quality of life [74]. A recent randomized CAM use in early-stage breast cancer within a year of controlled trial of a 6-week MBSR program for breast cancer diagnosis suggested that such use may be motivated by the survivors reported reduced anxiety, depression, and fear of expected benefits and may not necessarily indicate distress or recurrence and better perception of physical functioning in dissatisfaction [65]. the intervention group [78]. Sixteen studies have shown that participation in pro- 4. Mind-Body Medicine grams consisting of traditional holistic yoga results in statistically significant improvements in stress, anxiety, Mind-body medicine (MBM) includes a variety of practices irritability, emotional well-being, sadness, energy, invigo- that enable the mind to influence body functions. Some of ration, cognitive function, relaxation, pain, sleep, mood, the early works in the area of MBM include research on depression, fatigue, symptom severity, hot flashes, appetite, transcendental meditation (TM) [66–69] and application of bowel function, nausea, vomiting, QOL, and tolerance of meditation techniques for stress reduction by Kabat-Zinn cancer treatment [73, 75, 76, 84–96]. The yoga interventions [70]; the latter was called mindfulness-based stress reduction typically lasted from 6 to 24 weeks and most often involved 4 Evidence-Based Complementary and Alternative Medicine weekly sessions of 75–120 minutes. The types of yoga standard medical care during radiation therapy [113]and used in the interventions also varied; the majority of the reduced fatigue in women who underwent lumpectomy for interventions used systems of yoga that involved meditation, breast cancer [114]. breathing, gentle yoga, and restorative yoga. These studies indicate that clinicians and patients are very receptive to stress reduction programs, including yoga, as a treatment 5. Herbal and Natural Products modality in traditional cancer centers and that it is feasible to recruit patients and conduct these types of interventions The use of herbal and natural supplements has dramatically in a wide variety of communities. A large community-based increased over the last ten years. Herbal (or natural) trial of a yoga program in cancer survivors was found to supplements are commonly used to combat stress-related improve their sleep, fatigue, quality of life [97], circadian symptoms such as anxiety, depression, insomnia, and fatigue rhythm, anxiety, and mood [98].Somestudiesofyogahave [115–117]. Herbal supplements are one of the three most examined its effects on measures of stress and its physiologic common forms of CAM used by cancer patients [116–119]. parameters. Yogic relaxation training has been found to In a recent study conducted by MD Anderson Cancer Center, reduce perceived stress after surgery in breast cancer [99]; 52% of 309 cancer patients reported using one or more forms another study of yoga during radiation treatment in breast of CAM modalities, and 26% reported herbal supplement cancer patients observed a 27% reduction in perceived stress usage [118]. Unfortunately, little evidence supports the score [84]. A recent study of Iyengar yoga in breast cancer effectiveness of herbal interventions for long-term reduction survivors observed reduced morning and evening cortisol in stress [115, 116]. levels along with improved fatigue, emotional well-being Sedative herbal and natural supplements have been [73], and vitality and reduced pain [96] following eight- and used since the middle ages to reduce stress and improve twelve-week interventions. quality of life. Herbal supplements are usually ingested as Tai Chi Chuan (TCC) is a form of martial arts used extracts (i.e., tea) or capsules or inhaled as essential oils (i.e., for centuries in China as a health exercise involving a aromatherapy). Commonly used herbal supplements for series of individual movements continuously linked together stress include lemon balm, kava, valerian root, lavender, St. and performed in conjunction with deep breathing and John’s wort, and passionflower [115–117]. Lemon balm has mental concentration. At least 20 prospective, randomized, proven effective and safe for relieving stress with long-term controlled clinical trials in a number of populations includ- use [116, 120–123]. Substantial evidence indicates that kava ing the elderly, cardiovascular patients, and patients with reduces anxiety and stress; however, it has been implicated chronic diseases have been conducted using TCC [100]. in liver failure and is therefore not clinically recommended TCC as an intervention may provide benefits to cancer but may be safe for short-term use in patients with mild to survivors related to physical deconditioning, cardiovascular moderate anxiety [115, 116, 119, 122, 124, 125]. Although disease risk, and psychological stress. In a randomized, valerian is considered safe at low doses for less than one controlled clinical trial conducted by Mustian et al., women month, no clinical evidence supports its use for anxiety or who completed treatment for breast cancer and received distress [116, 121–123, 125]; however, combined with lemon TCC demonstrated significant improvements in functional balm and kava it has been associated with reduction in stress- capacity, aerobic capacity, muscular strength and flexibil- related insomnia [120, 121, 125]. Lavender aromatherapy ity, self-esteem, bone health, immune function, and QOL is recommended to relieve anxiety and depression and [101–106]. Thus, physical activity seems to be an interven- promote calmness and positivity, but definitive evidence for tion capable of reducing anxiety and distress associated with efficacy is lacking [117, 123, 124]. A randomized controlled the cancer experience. Conversely, higher levels of anxiety trial which combined lavender essential oils with massage may reduce the likelihood of participation in physical activity in patients with cancer reported reductions in distress, following cancer treatment. but the study was not able to conclude whether lavender Acupuncture, a mind-body technique that is also classi- aromatherapy supplemented the effects of massage [124]. fied as manipulative body-based technique and energy-based Likewise, passionflower demonstrated a reduction in anxiety technique, has been shown to ameliorate distress in healthy compared to oxazepam [116, 126]. St. John’s wort is used adults [107]. It has also been found to reduce fatigue and mostly for depression and is less popular for treating anxiety distress in patients with advanced breast and ovarian cancer and distress [116]. Some evidence suggests that Siberian [108]. A recent systematic review of 15 studies of CAM ginseng and European mistletoe may reduce side effects of interventions (acupuncture, massage, yoga and relaxation, cancer treatment and improve quality of life [127–129]. hypnosis, vitamins, and medical qigong) in cancer-related Possible mechanisms of some herbals in stress are depicted in fatigue reported most benefits from acupuncture [109]. Figure 2. Thus patients with high levels of stress could benefit Acupuncture has also been found beneficial in cancer-related from herbal supplements [116–118, 124] but patients should vasomotor symptoms [110] and anxiety associated with hot discuss any proposed supplement use with their physician to flashes [111] and other symptoms associated with cancer ensure safety. such as pain, nausea and vomiting, fatigue that could be Researchers have studied the effects of numerous vita- related to stress [112]. Another MBM technique, hypnosis, mins, minerals, and dietary supplements on psycholog- combined with cognitive behavioral therapy prevented the ical stress. The most promising include the B vitamins increase of fatigue in breast cancer patients compared to (folic acid, B6 and B12) and vitamin D. However, there is a Evidence-Based Complementary and Alternative Medicine 5 dearth of investigation of the effects of these compounds on Reiki, therapeutic touch, healing touch, and Qigong involve psychological distress in cancer patients, perhaps due to the manipulation of the body energy fields. Polarity therapy reluctance of oncologists to prescribe vitamin and mineral (PT) has been shown to reduce cancer-related fatigue during supplementation during treatment, believing that the antiox- radiation treatment [168] when compared with modified idant effects of these supplements might decrease treatment massage therapy and standard care [169]; the potential for its efficacy. Nevertheless, the few studies available show that use in management of cancer-related stress can be explored vitamin and mineral supplementation administered during since PT has been shown to decrease stress in caregivers of treatment do not reduce treatment efficacy [130, 131]. dementia patients [170]. The fact that Reiki ameliorates pain Following the completion of treatment, cancer survivors use in advanced cancer patients [171] and reduces cancer-related vitamin and mineral supplementation at a higher rate than fatigue [172] may indicate that it can also lower cancer- the general population, with 64–81% of cancer survivors related stress, although there is no supporting evidence. The using supplements compared to approximately 50% of the trials of music in reducing stress in cancer have not yielded general population [132]. consistent results; one study in women with metastatic breast A large amount of the literature reports the effects of B cancer showed no significant differences in the music therapy vitamins (folic acid (B9), pyridoxine (B6), and cobalamins led by a therapist and the usual care groups [173]. However, (B12)) on psychological stress, particularly depression. There one study of music imagery intervention has suggested is a biological rationale for the association of B vitamins reduction of anxiety in adults undergoing chemotherapy, with psychological stress. B vitamin deficiency can lead to particularly those with lower initial stress levels [174]. an increase in homocysteine levels [133], which is associ- ated with increased depression rates [134]. Cross-sectional studies commonly find that patients with psychological 7. Exercise stress disorders have deficient folic acid levels [135–137]. Exercise training improves resilience to stress [175, 176]. Similar findings were reported for vitamin B12, with low A 6-week exercise intervention in patients receiving levels seen in patients with psychological distress [138– chemotherapy was found to have beneficial effects on 140]. Evidence from cross-sectional studies also indicates psychological distress [177]. Similarly, in postoperative that psychologically stressed patients have low levels of breast cancer patients receiving chemotherapy, a 12-week vitamin B6 [141, 142], but the evidence is not as strong home-based exercise intervention was found to improve as for folic acid or vitamin B12. Other studies show that mood disturbance compared to a nonexercise control individuals deficient in B vitamins have a poorer response group [178]. Researchers have found that cancer patients to antidepression therapy and higher rates of relapse of who exercised before undergoing treatment for cancer depression. Randomized trials have shown that adding folic experienced lower levels of anxiety and depression [179]. acid and vitamin B12 supplementation to existing treatments ffi Early-stage breast cancer patients undergoing a 6-week increases the e cacy of antidepressant treatment [143–145]. walking exercise intervention during radiation treatment Recent research has shown that vitamin D may be also noted improvements in anxiety [180]. In colorectal involved in psychological well-being. Vitamin D plays a cancer survivors, a relationship was established between crucial role in brain development and function [146, 147]. psychological distress, anxiety, and participation in physical A recent study in fibromyalgia patients found a significantly activity. Cancer survivors with higher levels of anxiety are higher rate of vitamin D deficiency in patients with anxiety less likely to participate in physical activity [181]. [148]. Other studies have associated vitamin D deficiency with cognitive impairment [149, 150], mood disorders [150], and depression [148, 151]. Vitamin D deficiency has also 8. CAM in Children, Adolescents, and been associated with seasonal affective disorder (SAD), a the Elderly with Cancer condition with depression-like symptoms that occur in winter, when vitamin D levels are typically at their lowest A recent systematic review estimated that the prevalence of [152]. Randomized trials also show that vitamin D supple- CAM use by children with cancer ranges from 6% to 91%, mentation may ameliorate symptoms of depression [151] with significant variation between studies [182]. Children’s and SAD [153, 154]. Thus, research indicates that individuals and adolescents’ use of CAM has been linked to parents’ with low levels of folic acid, vitamin B12, and vitamin D have use of CAM [183, 184]. Parents with higher educational higher rates of psychological stress, and limited evidence backgrounds are more likely to consider [185]andto from randomized trials show that supplementation with use [182] CAM approaches for their children, although these vitamins may improve anxiety, mood disorders, and no consistent correlations between CAM use and parental depression. income, child age, or ethnicity have been reported [182]. CAM use and consideration were shown to be positively related to a lower survival perspective [186]andfewer 6. Manipulative and Other CAM Therapies days since relapse [185], respectively, suggesting that CAM therapies may be a coping strategy for families in an attempt Research on massage therapy, a manipulative body-based to try every possible approach for curing or alleviating pain technique, for stress reduction in cancer populations has and distress in their children. A review by Sencer and Kelly not provided consistent results [164–167]. Polarity Therapy, [187] suggests that families’ use of CAM may increase their 6 Evidence-Based Complementary and Alternative Medicine

Cancer/cancer treatment

Stress Anxiety Relaxant Depression Antioxidant Lavender Sleep disturbance Lemon balm Fatigue

Sedative Anti-inflammatory GABAA receptor (inhibit NE; increase agonist (inhibit NFκB and/or COX2) serotonin) Kava Ginseng Valerian St. John’s wort Mistletoe Passionflower

Figure 2: Mechanisms of herbal supplements for stress. Cancer and cancer treatment affect a patient’s quality of life resulting in various symptoms of stress, such as anxiety, depression, sleep disturbance, and fatigue [155]. The human body’s response to such stressors involves many different mechanistic pathways. This diagram outlines the mechanisms by which herbal supplements reduce stress-related symptoms in cancer patients. The majority of herbal supplements have anti-inflammatory properties, but their primary target of action is different. Lavender acts as vascular smooth muscle relaxant through nitric oxide/cGMP phosphorylation and myosin light chain dephosphorylation [156]. Lemon balm is an immune stimulating agent with potent free radical scavenging properties [157–159]. Kava and St. Johns’s wort function reduce norepinephrine (NE) and increase serotonin levels, similar to antianxiety drugs such as benzodiazepines [116, 122, 160]. Valerian and passionflower are GABAA receptor agonists that produce a sedative effect [161, 162]. Ginseng and mistletoe are potent anti- inflammatory agents that inhibit NFkB and/or COX2 [127, 163]. sense of control and active participation in treatment, and anxiety [201], and cognitive difficulties [202] also affect older therefore open discussion of CAM should be useful for adults. Cancer treatments can further exacerbate these age- physicians in building relationships with families and in related declines and stressors. Cancer survivors aged 65 and understanding all potential influences on the child’s care. older report more limitations in activities of daily living The quality of research related to CAM use in pediatric [203], a lower quality of life [204], lower self-rated health oncology has varied greatly from study to study. Within the [204], a greater incidence of frailty [203], and higher rates of past 10 years, there has been considerable movement towards dementia, depression, falls, incontinence, and osteoporosis more rigorous research testing, including randomized clini- [203]. Other stressors in this population include relocation, cal trials conducted through the Children’s Oncology Group financial changes with retirement, caring for grandchildren or other multisite studies [188–191]. There is a great need for and/or a spouse, the death of friends and family members, rigorous safety and efficacy trials, particularly for biologically chronic illnesses, and the fear of losing independence based therapies [188, 192]. Research has reported physical [205–208]. Stress is associated with depression in the elderly and psychological benefits from a massage intervention for [209]. Emotional stress is also a potential trigger impairing children with various cancers and blood disorders [193]; the mechanisms responsible for balance, increasing the risk however, another randomized trial of a combined massage of falls that can lead to hip and femur fractures [210]. and humor intervention found no significant differences These additional declines in physiological and psychological across groups in children undergoing stem cell transplants function likely exacerbate the stress experienced by older [190]. A trial of music video compared to audiotape and cancer survivors. usual care in adolescents and young adults undergoing stem- Physical activity and social interactions reduce functional cell transplantation suggested less distress in music group decline in the elderly [211]. Physical activity is also associated at 100-day follow-up [194]. Thus, several promising CAM with a reduction in stress and anxiety. The American College therapies are available to help children with cancer to manage of Sports Medicine (ACSM) recommends that older adults, emotional and physical distress related to cancer and its even those with chronic medical conditions, participate in treatment; however, much work is needed to document their regular aerobic exercise training (150–300 minutes per week) efficacy and safety. and resistance exercise training (at least 2 days a week) Aging alone is associated with declines in physical [212]. The exercise prescription for those older adults who function, including reduction in functional capacity [195, are functionally limited should be tailored and progressed 196], reduced muscular strength [197], arthralgia [198], and gradually [213].Theliteraturesupportstheuseofphysical reductions in bone mineral density [199]. Depression [200], activity in cancer survivors younger than 65, but little has Evidence-Based Complementary and Alternative Medicine 7 been done to determine the benefits of physical activity the most from herbal supplements; therefore, studies or other forms of complementary and alternative medicine are needed to examine their efficacy as well as safety. for cancer survivors who are 65 years of age and older. (5) Most research on vitamins and supplements con- Researchers have investigated the benefits of Tai Chi Chuan ducted in noncancer patients show promise in reliev- in older adults without a history of cancer, finding that ing stress; further trials in cancer patients are needed ffi Tai Chi can reduce depression [214], improve self-e cacy to demonstrate the safety of vitamin B and D sup- [215], improve muscular strength and endurance [216], and plementation in cancer patients receiving treatment improve balance and reduce falls [217]. Yoga can improve before testing their efficacy on psychological stress. gait [218], quality of life [219], and depression [220] in the elderly. Research is limited concerning the implementation (6) Physical activity may be helpful in reducing anxiety of CAM in older cancer survivors in particular, despite and distress in cancer survivors; however, the role of ff its promising impact on physiological and psychological anxiety in a ecting physical activity should be given function. Stress in particular has received very little research consideration while designing intervention studies in focus in older cancer survivors, but because the benefits of cancer population. physical activity are so profound in older adults, it is an (7) Research on CAM therapies for stress in child- important and promising area of research. hood cancers is insufficient. Several promising CAM therapies may help children with cancer manage 9. Conclusions and Future Directions emotional and physical distress related to cancer and its treatment after the safety and utility of such Cancer-related stress affects all patients with cancer and therapies has been established. negatively impacts cancer outcomes in terms of response to (8) Stress in older cancer survivors is an important treatment, quality of life, disease progression, and survival in and promising area that is desperately needed to be different phases of their experience. Feasibility of interven- examined as older adults are at much greater risk of tion with several CAM techniques and products commonly developing cancer than young adults. It is especially used by cancer patients and survivors has been established important since by the year 2030, 70% of cancer in some cancer populations: for example, mind-body tech- patients will be elderly. niques of meditation, yoga, Tai Chi Chuan, acupuncture, manipulative techniques massage, energy-based polarity Although some CAM techniques/products could be therapy and Reiki, and some natural products. Efficacy integrated into cancer care, much more research is needed of some CAM techniques and products in reducing stress to confirm their efficacy. Moreover, the wide variety of study and/or stress-related symptoms in patients with cancer has designs and types of interventions are an obstacle to reach been documented effective conclusions. Additionally, there is a need to study mechanisms of action of various techniques and products (1) Mindfulness-based stress reduction program with using innovative designs such as research on the effects of components similar to yoga showed reduction CAM on apoptotic and angiogenesis pathways; this may of stress levels in population of breast cancer be helpful in understanding tumor development and its and prostate cancer patients and improvements in progression and applying CAM as a part of personalized endocrine indices of stress were also reported. Some medicine to ensure cancer-free and better quality of life. studies of yoga intervention have shown significant CAM is primarily used by cancer patients to relieve stress reduction while some have shown benefi- disease- and treatment-related side effects. Although many of cial effects on symptoms associated with stress for the symptoms usually subside after treatment, CAM utiliza- example, fatigue, sleep disturbances, hot flashes, and tioncouldhelpmaintainasymptom-freeandgoodquality quality of life. However, the majority of studies of of life during cancer treatment. The word “stress” cannot yoga were conducted in small samples of patients and be over emphasized when associated with cancer experience. there was a wide range of the length of intervention. Stress reported by cancer patients could potentially alert This area of mind-body intervention seems to be healthcare providers about the impending negative outcomes promising in cancer; however, lack of uniformity of of cancer treatments. Most CAM techniques are relatively the intervention program in terms of its length and inexpensive, simple to administer or practice, and encompass content makes it difficult to compare study results. the holistic nature of healing. CAM for stress management Larger study samples with the use of comparable could restore a patient’s sense of control, maintain quality of intervention programs may be more conclusive. life, reduce risk of cancer recurrence, and minimize physician (2) Acupuncture can relieve anxiety, fatigue, and distress visits. The first prescription following a cancer-related visit associated with advanced cancer. with a healthcare provider may be for stress management technique/product. Further research on CAM and stress can (3) Practice of Tai Chi Chuan may be helpful in improv- help healthcare professionals as well as patients with their ing quality of life. understanding of the significance of safe use of integrative (4) Some herbs like lemon balm may be used, long in modes of treatment, better compliance with conventional the term for relieving stress. Most current research treatment, improve treatment outcomes and survival, and suggests that patients with high levels of stress benefit possibly reduce the risk of recurrence of cancer. Thus, CAM 8 Evidence-Based Complementary and Alternative Medicine for stress management could be a critical component of disease,” JournalofPainandSymptomManagement, vol. 31, cancer care. no. 1, pp. 58–69, 2006. [16] L. E. Carlson, S. L. Groff,O.Maciejewski,andB.D.Bultz, “Screening for distress in lung and breast cancer outpatients: Acknowledgments a randomized controlled trial,” Journal of Clinical Oncology, vol. 28, no. 33, pp. 4884–4891, 2010. The authors would like to thank Dr. Joseph Roscoe and Dr. [17] G. Van der Pompe, H. J. Duivenvoorden, M. H. Antoni, A. Susan Rosenthal for their support of this project and their Visser,andC.J.Heijnen,“Effectiveness of a short-term group suggestions regarding this paper. This paper was supported psychotherapy program on endocrine and immune function by grant NCI R25CA102618. in breast cancer patients: an exploratory study,” Journal of Psychosomatic Research, vol. 42, no. 5, pp. 453–466, 1997. [18] M. H. Antoni, S. R. Wimberly, S. C. Lechner et al., “Reducion References of cancer-specific though intrusuions and anxiety symptoms with a stress management intervention among women [1] NCCN, Distress management version 1.2011, http://www undergoing treatment for breast cancer,” American Journal of .nccn.org/professionals/physician gls/pdf/distress.pdf, 2011. Psychiatry, vol. 163, no. 10, pp. 1791–1797, 2006. [2] J. V. Pasacreta and M. Pickett, “Psychosocial aspects of [19] D. G. Cruess, M. H. Antoni, B. A. McGregor et al., palliative care,” Seminars in oncology nursing,vol.14,no.2, “Cognitive-behavioral stress management reduces serum pp. 110–120, 1998. cortisol by enhancing benefit finding among women being [3] D. E. Bailey Jr, M. Wallace, and M. H. Mishel, “Watching, treated for early stage breast cancer,” Psychosomatic Medicine, waiting and uncertainty in prostate cancer,” Journal of vol. 62, no. 3, pp. 304–308, 2000. Clinical Nursing, vol. 16, no. 4, pp. 734–741, 2007. [20] K. M. Phillips, M. H. Antoni, S. C. Lechner et al., [4] B. B. Germino, M. H. Mishel, M. Belyea, L. Harris, A. Ware, “Stress management intervention reduces serum cortisol and J. Mohler, “Uncertainty in prostate cancer: ethnic and and increases relaxation during treatment for nonmetastatic family patterns,” Cancer Practice, vol. 6, no. 2, pp. 107–113, breast cancer,” Psychosomatic Medicine,vol.70,no.9,pp. 1998. 1044–1049, 2008. [5] M. H. Mishel, B. B. Germino, L. Lin et al., “Managing [21] L. E. Carlson, M. Speca, K. D. Patel, and E. Goodey, uncertainty about treatment decision making in early stage “Mindfulness-based stress reduction in relation to quality prostate cancer: a randomized clinical trial,” Patient Educa- of life, mood, symptoms of stress and levels of cortisol, tion and Counseling, vol. 77, no. 3, pp. 349–359, 2009. dehydroepiandrosterone sulfate (DHEAS) and melatonin [6] M. H. Mishel and D. S. Sorenson, “Uncertainty in gynecolog- in breast and prostate cancer outpatients,” Psychoneuroen- ical cancer: a test of the mediating functions of mastery and docrinology, vol. 29, no. 4, pp. 448–474, 2004. coping,” Nursing Research, vol. 40, no. 3, pp. 167–171, 1991. [22] R. H. Matousek, J. C. Pruessner, and P. L. Dobkin, “Changes [7] N. K. Aaronson, B. E. Meyerowitz, M. Bard et al., “Quality in the cortisol awakening response (CAR) following partic- of life research in oncology. Past achievements and future ipation in Mindfulness-Based Stress Reduction in women priorities,” Cancer, vol. 67, supplement 3, pp. 839–843, 1991. who completed treatment for breast cancer,” Complementary [8] W. H. Redd, P. M. Silberfarb, B. L. Andersen et al., Therapies in Clinical Practice, vol. 17, no. 2, pp. 65–70, 2011. “Physiologic and psychobehavioral research in oncology,” [23] D. M. Eisenberg, R. C. Kessler, C. Foster, F. E. Norlock, D. Cancer, vol. 67, no. 3, pp. 813–822, 1991. R. Calkins, and T. L. Delbanco, “Unconventional medicine [9] D. Spiegel, “Psychosocial aspects of breast cancer treatment,” in the United States. Prevalence, costs, and patterns of use,” Seminars in Oncology, vol. 24, no. 1, pp. S1–S1, 1997. New England Journal of Medicine, vol. 328, no. 4, pp. 246–252, [10] P. Herschbach, M. Keller, L. Knight et al., “Psychological 1993. problems of cancer patients: a cancer distress screening with a [24] P. J. Mansky and D. B. Wallerstedt, “Complementary cancer-specific questionnaire,” British Journal of Cancer, vol. medicine in palliative care and cancer symptom manage- 91, no. 3, pp. 504–511, 2004. ment,” Cancer Journal, vol. 12, no. 5, pp. 425–431, 2006. [11] C. S. Cleeland, T. R. Mendoza, X. S. Wang et al., “Assessing [25]V.E.vonGruenigen,H.E.Frasure,E.L.Jenison,M. symptom distress in cancer patients: the M.D. Anderson P. Hopkins, and K. M. Gil, “Longitudinal assessment of Symptom inventory,” Cancer, vol. 89, no. 7, pp. 1634–1646, quality of life and lifestyle in newly diagnosed ovarian cancer 2000. patients: the roles of surgery and chemotherapy,” Gynecologic [12] Y. Wengstrom, C. Haggmark,¨ H. Strander, and C. Forsberg, Oncology, vol. 103, no. 1, pp. 120–126, 2006. “Perceived symptoms and quality of life in women with [26] A. Baum, L. Cohen, and M. Hall, “Control and intrusive breast cancer receiving radiation therapy,” European Journal memories as possible determinants of chronic stress,” Psycho- of Oncology Nursing, vol. 4, no. 2, pp. 78–88, 2000. somatic Medicine, vol. 55, no. 3, pp. 274–286, 1993. [13] M. Ewertz and A. B. Jensen, “Late effects of breast cancer [27]E.O.Johnson,T.C.Kamilaris,G.P.Chrousos,andP. treatment and potentials for rehabilitation,” Acta Oncologica, W. Gold, “Mechanisms of stress: a dynamic overview of vol. 50, no. 2, pp. 187–193, 2011. hormonal and behavioral homeostasis,” Neuroscience and [14]W.Gao,M.I.Bennett,D.Stark,S.Murray,andI.J.Hig- Biobehavioral Reviews, vol. 16, no. 2, pp. 115–130, 1992. ginson, “Psychological distress in cancer from survivorship [28] K. Szemeredi, G. Bagdy, R. Stull, A. E. Calogero, I. J. to end of life care: prevalence, associated factors and clinical Kopin, and D. S. Goldstein, “Sympathoadrenomedullary implications,” European Journal of Cancer, vol. 46, no. 11, pp. inhibition by chronic glucocorticoid treatment in conscious 2036–2044, 2010. rats,” Endocrinology, vol. 123, no. 5, pp. 2585–2590, 1988. [15] J. P. Solano, B. Gomes, and I. J. Higginson, “A comparison [29] P. J. Fitzgerald, “Is norepinephrine an etiological factor in of symptom prevalence in far advanced cancer, AIDS, heart some types of cancer?” International Journal of Cancer, vol. disease, chronic obstructive pulmonary disease and renal 124, no. 2, pp. 257–263, 2009. Evidence-Based Complementary and Alternative Medicine 9

[30] K. S. R. Sastry, Y. Karpova, S. Prokopovich et al., inflammatory diseases,” Immunology and Allergy Clinics of “Epinephrine protects cancer cells from apoptosis via activa- North America, vol. 31, no. 1, pp. 133–140, 2011. tion of cAMP-dependent protein kinase and BAD phospho- [46] S. K. Agarwal and G. D. Marshall Jr, “Stress effects on rylation,” Journal of Biological Chemistry, vol. 282, no. 19, pp. immunity and its application to clinical immunology,” 14094–14100, 2007. Clinical and Experimental Allergy, vol. 31, no. 1, pp. 25–31, [31] G. Van der Pompe, M. H. Antoni, and C. J. Heijnen, 2001. “Elevated basal cortisol levels and attenuated ACTH and [47] J. A. Moynihan, “Mechanisms of stress-induced modulation cortisol responses to a behavioral challenge in women with of immunity,” Brain, Behavior, and Immunity, vol. 17, metastatic breast cancer,” Psychoneuroendocrinology, vol. 21, supplement 1, pp. S11–S16, 2003. no. 4, pp. 361–374, 1996. [48]E.M.V.Reiche,S.O.V.Nunes,andH.K.Morimoto, [32] H. C. Abercrombie, J. Giese-Davis, S. Sephton, E. S. Epel, J. “Stress, depression, the immune system, and cancer,” Lancet M. Turner-Cobb, and D. Spiegel, “Flattened cortisol rhythms Oncology, vol. 5, no. 10, pp. 617–625, 2004. in metastatic breast cancer patients,” Psychoneuroendocrinol- [49] W. Wu, T. Yamaura, K. Murakami et al., “Social isolation ogy, vol. 29, no. 8, pp. 1082–1092, 2004. stress enhanced liver metastasis of murine colon 26-L5 [33] S. E. Sephton, R. M. Sapolsky, H. C. Kraemer, and D. Spiegel, carcinoma cells by suppressing immune responses in mice,” “Diurnal cortisol rhythm as a predictor of breast cancer Life Sciences, vol. 66, no. 19, pp. 1827–1838, 2000. survival,” Journal of the National Cancer Institute, vol. 92, no. [50] W. Wu, J. Murata, K. Hayashi, T. Yamaura, N. Mitani, and 12, pp. 994–1000, 2000. I. Saiki, “Social isolation stress impairs the resistance of [34] B. W. Penninx, J. M. Guralnik, M. Pahor et al., “Chronically mice to experimental liver metastasis of murine colon 26-L5 depressed mood and cancer risk in older persons,” Journal of carcinoma cells,” Biological and Pharmaceutical Bulletin, vol. the National Cancer Institute, vol. 90, no. 24, pp. 1888–1893, 24, no. 7, pp. 772–776, 2001. 1998. [51] I. Herr, E. Ucur, K. Herzer et al., “Glucocorticoid cotreat- [35] M. Watson, J. S. Haviland, S. Greer, J. Davidson, and J. M. ment induces apoptosis resistance toward cancer therapy in Bliss, “Influence of psychological response on survival in carcinomas,” Cancer Research, vol. 63, no. 12, pp. 3112–3120, breast cancer: a population-based cohort study,” The Lancet, 2003. vol. 354, no. 9187, pp. 1331–1336, 1999. [52] K. S. R. Sastry, Y. Karpova, S. Prokopovich et al., [36] M. Stommel, B. A. Given, and C. W. Given, “Depression “Epinephrine protects cancer cells from apoptosis via activa- and functional status as predictors of death among cancer tion of cAMP-dependent protein kinase and BAD phospho- patients,” Cancer, vol. 94, no. 10, pp. 2719–2727, 2002. rylation,” Journal of Biological Chemistry, vol. 282, no. 19, pp. [37] F. R. Loberiza, J. D. Rizzo, C. N. Bredeson et al., “Association 14094–14100, 2007. of depressive syndrome and early deaths among patients after [53] A. Bikfalvi, “Significance of angiogenesis in tumour progres- stem-cell transplantation for malignant diseases,” Journal of sion and metastasis,” EuropeanJournalofCancerA, vol. 31, Clinical Oncology, vol. 20, no. 8, pp. 2118–2126, 2002. no. 7-8, pp. 1101–1104, 1995. [38] B. Seruga, H. Zhang, L. J. Bernstein, and I. F. Tannock, [54] J. M. Fredriksson, J. M. Lindquist, G. E. Bronnikov, and J. “Cytokines and their relationship to the symptoms and Nedergaard, “Norepinephrine induces vascular endothelial outcome of cancer,” Nature Reviews Cancer, vol. 8, no. 11, growth factor gene expression in brown adipocytes through a pp. 887–899, 2008. β-adrenoreceptor/cAMP/protein kinase A pathway involving [39]S.K.Lutgendorf,A.K.Sood,M.H.Antonietal.,“Host Src but independently of Erk1/2,” Journal of Biological factors and cancer progression: biobehavioral signaling path- Chemistry, vol. 275, no. 18, pp. 13802–13811, 2000. ways and interventions,” Journal of Clinical Oncology, vol. 28, [55] S. K. Lutgendorf, S. Cole, E. Costanzo et al., “Stress- no. 26, pp. 4094–4099, 2010. related mediators stimulate vascular endothelial growth [40] J. L. Ryan, J. K. Carroll, E. P. Ryan, K. M. Mustian, K. Fiscella, factor secretion by two ovarian cancer cell lines,” Clinical and G. R. Morrow, “Mechanisms of cancer-related fatigue,” Cancer Research, vol. 9, no. 12, pp. 4514–4521, 2003. Oncologist, vol. 12, supplement 1, pp. 22–34, 2007. [56]E.V.Yang,E.L.Donovan,D.M.Benson,andR.Glaser, [41] M. C. Janelsins, K. M. Mustian, O. G. Palesh et al., “VEGF is differentially regulated in multiple myeloma- “Differential expression of cytokines in breast cancer patients derived cell lines by norepinephrine,” Brain, Behavior, and receiving different chemotherapies: implications for cogni- Immunity, vol. 22, no. 3, pp. 318–323, 2008. tive impairment research,” Supportive Care in Cancer, vol. 20, [57] P. H. Thaker, L. Y. Han, A. A. Kamat et al., “Chronic stress no. 4, pp. 831–9, 2012. promotes tumor growth and angiogenesis in a mouse model [42] J. E. Bower, P. A. Ganz, L. T. May et al., “Inflammatory of ovarian carcinoma,” Nature Medicine,vol.12,no.8,pp. biomarkers and fatigue during radiation therapy for breast 939–944, 2006. and prostate cancer,” Clinical Cancer Research, vol. 15, no. 17, [58] E. V. Yang, A. K. Sood, M. Chen et al., “Norepinephrine pp. 5534–5540, 2009. up-regulates the expression of vascular endothelial growth [43] J. E. Bower, P. A. Ganz, S. S. Dickerson, L. Petersen, N. Aziz, factor, matrix metalloproteinase (MMP)-2, and MMP-9 in andJ.L.Fahey,“Diurnalcortisolrhythmandfatigueinbreast nasopharyngeal carcinoma tumor cells,” Cancer Research, vol. cancer survivors,” Psychoneuroendocrinology, vol. 30, no. 1, 66, no. 21, pp. 10357–10364, 2006. pp. 92–100, 2005. [59] NCCAM, Expanding Horizons of Health Care Strategic Plan [44] J. E. Bower, P. A. Ganz, K. A. Desmond, J. H. Rowland, B. 2005–2009, National Center for Complementary and Alter- E. Meyerowitz, and T. R. Belin, “Fatigue in breast cancer native Medicine, Gaithersburg, Md, USA, 2004. survivors: occurrence, correlates, and impact on quality of [60] E. Ernst, “The current position of complementary/alternative life,” Journal of Clinical Oncology, vol. 18, no. 4, pp. 743–753, medicine in cancer,” European Journal of Cancer, vol. 39, no. 2000. 16, pp. 2273–2277, 2003. [45] G. D. Marshall Jr, “The adverse effects of psychological [61] J. M. Fouladbakhsh and M. Stommel, “Gender, symptom stress on immunoregulatory balance: applications to human experience, and use of complementary and alternative 10 Evidence-Based Complementary and Alternative Medicine

medicine practices among cancer survivors in the U.S. cancer [76] S. C. Danhauer, S. L. Mihalko, G. B. Russell et al., “Restorative population,” Oncology Nursing Forum,vol.37,no.1,pp.E7– yoga for women with breast cancer: finding from a random- E15, 2010. ized pilot study,” Psycho-Oncology, vol. 18, no. 4, pp. 360–368, [62]C.Buettner,C.H.Kroenke,R.S.Phillips,R.B.Davis,D.M. 2009. Eisenberg, and M. D. Holmes, “Correlates of use of different [77] C. A. Lengacher, M. P. Bennett, K. E. Kip, L. Gonzalez, P. types of complementary and alternative medicine by breast Jacobsen, and C. E. Cox, “Relief of symptoms, side effects, cancer survivors in the nurses’ health study,” Breast Cancer and psychological distress through use of complementary Research and Treatment, vol. 100, no. 2, pp. 219–227, 2006. and alternative medicine in women with breast cancer,” [63] D. A. Monti and J. Yang, “Complementary medicine in Oncology Nursing Forum, vol. 33, no. 1, pp. 97–104, 2006. chronic cancer care,” Seminars in Oncology, vol. 32, no. 2, pp. [78] C. A. Lengacher, V. Johnson-Mallard, J. Post-White et al., 225–231, 2005. “Randomized controlled trial of mindfulness-based stress [64] K. D. Stein, C. Kaw, C. Crammer, and T. Gansler, “The role reduction (MBSR) for survivors of breast cancer,” Psycho- of psychological functioning in the use of complementary Oncology, vol. 18, no. 12, pp. 1261–1272, 2009. and alternative methods among disease-free colorectal cancer [79] A. Moadel, C. Morgan, A. Fatone et al., “Seeking meaning survivors: a report from the American cancer society’s studies and hope: self-reported spiritual and existential needs among of cancer survivors,” Cancer, vol. 115, supplement 18, pp. an ethnically-diverse cancer patient population,” Psycho 4397–4408, 2009. Oncology, vol. 8, no. 5, pp. 378–385, 1999. [65] S. M. Alferi, M. H. Antoni, G. Ironson, K. M. Kilbourn, and [80] K. D. Chandwani, B. Thornton, G. H. Perkins et al., “Yoga C. S. Carver, “Factors predicting the use of complementary improves quality of life and benefit finding in women therapies in a multi-ethnic sample of early-stage breast undergoing radiotherapy for breast cancer,” Journal of the cancer patients,” Journal of the American Medical Women’s Society for Integrative Oncology, vol. 8, no. 2, pp. 43–55, 2010. Association, vol. 56, no. 3, pp. 120–126, 2001. [81] L. E. Carlson, M. Speca, K. D. Patel, and E. Goodey, [66] L. A. Hjelle, “Transcendental meditation and psychological “Mindfulness-based stress reduction in relation to quality health,” Perceptual and Motor Skills, vol. 39, no. 1, pp. 623– of life, mood, symptoms of stress and levels of cortisol, 628, 1974. dehydroepiandrosterone sulfate (DHEAS) and melatonin [67] M. E. McIntyre, F. H. Silverman, and W. D. Trotter, “Tran- in breast and prostate cancer outpatients,” Psychoneuroen- scendental meditation and stuttering: a preliminary report,” docrinology, vol. 29, no. 4, pp. 448–474, 2004. Perceptual and Motor Skills, vol. 39, no. 1, 1974. [82] M. Speca, L. E. Carlson, E. Goodey, and M. Angen, “A [68] D. W. Orme-Johnson, “Autonomic stability and transcenden- randomized, wait-list controlled clinical trial: the effect of tal meditation,” Psychosomatic Medicine,vol.35,no.4,pp. a mindfulness meditation-based stress reduction program 341–349, 1973. on mood and symptoms of stress in cancer outpatients,” [69] R. K. Wallace, “Physiological effects of transcendental medi- Psychosomatic Medicine, vol. 62, no. 5, pp. 613–622, 2000. tation,” Science, vol. 167, no. 3926, pp. 1751–1754, 1970. [83] L. E. Carlson and S. N. Garland, “Impact of mindfulness- [70] J. Kabat-Zinn, “An outpatient program in behavioral based stress reduction (MBSR) on sleep, mood, stress medicine for chronic pain patients based on the practice and fatigue symptoms in cancer outpatients,” International of mindfulness meditation: theoretical considerations and Journal of Behavioral Medicine, vol. 12, no. 4, pp. 278–285, preliminary results,” General Hospital Psychiatry, vol. 4, no. 2005. 1, pp. 33–47, 1982. [84] B. Banerjee, H. S. Vadiraj, A. Ram et al., “Effects of an inte- [71] V. S. Eschiti, “Lesson from comparison of CAM use by grated yoga program in modulating psychological stress and women with female-specific cancers to others: it’s time to radiation-induced genotoxic stress in breast cancer patients focus on interaction risks with CAM therapies,” Integrative undergoing radiotherapy,” Integrative Cancer Therapies, vol. Cancer Therapies, vol. 6, no. 4, pp. 313–344, 2007. 6, no. 3, pp. 242–250, 2007. [72] H. Greenlee, M. L. Kwan, I. J. Ergas et al., “Complementary [85]J.W.Carson,K.M.Carson,L.S.Porter,F.J.Keefe,H. and alternative therapy use before and after breast cancer Shaw, and J. M. Miller, “Yoga for women with metastatic diagnosis: the pathways study,” Breast Cancer Research and breast cancer: results from a pilot study,” JournalofPainand Treatment, vol. 117, no. 3, pp. 653–665, 2009. Symptom Management, vol. 33, no. 3, pp. 331–341, 2007. [73] J. Banasik, H. Williams, M. Haberman, S. E. Blank, and R. [86] L. Cohen, C. Warneke, R. T. Fouladi, M. A. Rodriguez, Bendel, “Effect of Iyengar yoga practice on fatigue and diur- and A. Chaoul-Reich, “Psychological adjustment and sleep nal salivary cortisol concentration in breast cancer survivors,” quality in a randomized trial of the effects of a tibetan yoga Journal of the American Academy of Nurse Practitioners, vol. intervention in patients with lymphoma,” Cancer, vol. 100, 23, no. 3, pp. 135–142, 2011. no. 10, pp. 2253–2260, 2004. [74] L. E. Carlson, M. Speca, P. Faris, and K. D. Patel, “One year [87]S.N.Culos-Reed,L.E.Carlson,L.M.Daroux,andS.Hately- pre-post intervention follow-up of psychological, immune, Aldous, “A pilot study of yoga for breast cancer survivors: endocrine and blood pressure outcomes of mindfulness- physical and psychological benefits,” Psycho-Oncology, vol. based stress reduction (MBSR) in breast and prostate cancer 15, no. 10, pp. 891–897, 2006. outpatients,” Brain, Behavior, and Immunity,vol.21,no.8, [88] S. C. Danhauer, J. A. Tooze, D. F. Farmer et al., “Restorative pp. 1038–1049, 2007. yoga for women with ovarian or breast cancer: findings from [75]J.W.Carson,K.M.Carson,L.S.Porter,F.J.Keefe,andV. a pilot study,” Journal of the Society for Integrative Oncology, L. Seewaldt, “Yoga of Awareness program for menopausal vol. 6, no. 2, pp. 47–58, 2008. symptoms in breast cancer survivors:r from a randomized [89] C. D. Joseph, “Psychological supportive therapy for cancer trial,” Supportive Care in Cancer, vol. 17, no. 10, pp. 1301– patients,” Indian Journal of Cancer, vol. 20, no. 5, pp. 268– 1309, 2009. 270, 1983. Evidence-Based Complementary and Alternative Medicine 11

[90] A. B. Moadel, C. Shah, J. Wylie-Rosett et al., “Randomized [103] K. M. Mustian, J. A. Katula, and H. Zhao, “A pilot study to controlled trial of yoga among a multiethnic sample of breast assess the influence of Tai Chi Chuan on functional capacity cancer patients: effects on quality of life,” Journal of Clinical among breast cancer survivors,” Journal of Supportive Oncol- Oncology, vol. 25, no. 28, pp. 4387–4395, 2007. ogy, vol. 4, no. 3, pp. 139–145, 2006. [91] R. M. Raghavendra, R. Nagarathna, H. R. Nagendra et al., [104] K. Mustian, O. Palesh, and S. Flecksteiner, “Tai Chi Chuan for “Effects of an integrated yoga programme on chemotherapy- breast cancer survivors,” Medicine and Sport Science, vol. 52, induced nausea and emesis in breast cancer patients,” pp. 209–217, 2008. European Journal of Cancer Care, vol. 16, no. 6, pp. 462–474, [105] L. J. Peppone, K. M. Mustian, M. C. Janelsins et al., “Effects 2007. of a structured weight-bearing exercise program on bone [92] M. R. Rao, N. Raghuram, H. R. Nagendra et al., “Anx- metabolism among breast cancer survivors: a feasibility trial,” iolytic effects of a yoga program in early breast cancer Clinical Breast Cancer, vol. 10, no. 3, pp. 224–229, 2010. patients undergoing conventional treatment: a randomized [106] K. M. Mustian, J. A. Roscoe, G. R. Morrow, O. G. Palesh, controlled trial,” Complementary Therapies in Medicine, vol. and S. Kohli, “Tai Chi Chuan, immune function, and 17, no. 1, pp. 1–8, 2009. cardiorespiratory fitness among breast cancer survivors,” [93] R. M. Rao, S. Telles, H. R. Nagendra et al., “Effects of Annals of Behavioral Medicine, vol. 33, p. 95, 2007. yoga on natural killer cell counts in early breast cancer [107] T. S. Pavao,˜ P. Vianna, M. M. Pillat, A. B. Machado, patients undergoing conventional treatment. Comment to: and M. E. Bauer, “Acupuncture is effective to attenuate recreational music-making modulates natural killer cell stress and stimulate lymphocyte proliferation in the elderly,” activity, cytokines, and mood states in corporate employees Neuroscience Letters, vol. 484, no. 1, pp. 47–50, 2010. Masatada Wachi, Masahiro Koyama, Masanori Utsuyama, [108] E. Dean-Clower, A. M. Doherty-Gilman, A. Keshaviah et al., Barry B. Bittman, Masanobu Kitagawa, Katsuiku Hirokawa “Acupuncture as palliative therapy for physical symptoms Med Sci Monit, 2007, 13(2): CR57–70,” Medical Science and quality of life for advanced cancer patients,” Integrative Monitor, vol. 14, no. 2, pp. LE3–LE4. Cancer Therapies, vol. 9, no. 2, pp. 158–167, 2010. [94] E. Rosenbaum, H. Gautier, P. Fobair et al., “Cancer support- [109] J. Finnegan-John, A. Molassiotis, A. Richardson, and E. ive care, improving the quality of life for cancer patients. A Ream, “A systematic review of complementary and Alterna- program evaluation report,” Supportive Care in Cancer, vol. tive medicine interventions in the management of cancer- 12, no. 5, pp. 293–301, 2004. related fatigue,” BMJ Support Palliat Care, vol. 1, p. A12, 2011. [95] H. S. Vadiraja, R. M. Raghavendra, R. Nagarathna et al., ff [110] E. M. Walker, A. I. Rodriguez, B. Kohn et al., “Acupunc- “E ects of a Yoga program on cortisol rhythm and mood ture versus venlafaxine for the management of vasomotor states in early breast cancer patients undergoing adjuvant symptoms in patients with hormone receptor-positive breast radiotherapy: a randomized controlled trial,” Integrative cancer: a randomized controlled trial,” Journal of Clinical Cancer Therapies, vol. 8, no. 1, pp. 37–46, 2009. Oncology, vol. 28, no. 4, pp. 634–640, 2010. [96] A. E. Speed-Andrews, C. Stevinson, L. J. Belanger, J. J. Mirus, [111] B. A. de Valois, T. E. Young, N. Robinson, C. McCourt, and E. and K. S. Courneya, “Pilot evaluation of an Iyengar yoga J. Maher, “Using traditional acupuncture for breast cancer- program for breast cancer survivors,” Cancer Nursing, vol. 33, related hot flashes and night sweats,” Journal of Alternative no. 5, pp. 369–381, 2010. ff and Complementary Medicine, vol. 16, no. 10, pp. 1047–1057, [97] K. M. Mustian, O. Palesh, L. Sprod et al., “E ect of YOCAS 2010. yoga on sleep, fatigue, and quality of life: a URCC CCOP [112] D. O’Regan and J. Filshie, “Acupuncture and cancer,” Auto- randomized, controlled clinical trial among 410 cancer nomic Neuroscience, vol. 157, no. 1-2, pp. 96–100, 2010. survivors,” in Proceedings of the 2010 ASCO Annual Meeting, Chicago, Ill, USA, 2010. [113] G. H. Montgomery, M. Kangas, D. David et al., “Fatigue during breast cancer radiotherapy: an initial randomized [98] K. M. Mustian, O. Palesh, L. Sprod et al., “Effect of YOCAS study of cognitive-behavioral therapy plus hypnosis,” Health yoga on circadian rhythm, anxiety, and mood: a URCC Psychology, vol. 28, no. 3, pp. 317–322, 2009. CCOP randomized, controlled clinical trial among 410 cancer survivors,” in Proceedings of the 2010 ASCO Annual [114] G. H. Montgomery, D. H. Bovbjerg, J. B. Schnur et al., “A Meeting, Chicago, Ill, USA, 2011. randomized clinical trial of a brief hypnosis intervention to ff [99] T. Kovacic and M. Kovacic, “Impact of relaxation training control side e ects in breast surgery patients,” Journal of the according to Yoga in Daily Life system on perceived stress National Cancer Institute, vol. 99, no. 17, pp. 1304–1312, after breast cancer surgery,” Integrative Cancer Therapies, vol. 2007. 10, no. 1, pp. 16–26, 2011. [115] E. Ernst, “Herbal remedies for anxiety-a systematic review of [100] P. Mansky, T. Sannes, D. Wallerstedt et al., “Tai chi chuan: controlled clinical trials,” Phytomedicine,vol.13,no.3,pp. mind-body practice or exercise intervention? Studying the 205–208, 2006. benefit for cancer survivors,” Integrative Cancer Therapies, [116] S. A. Saeed, R. M. Bloch, and D. J. Antonacci, “Herbal vol. 5, no. 3, pp. 192–201, 2006. and dietary supplements for treatment of anxiety disorders,” [101] M. C. Janelsins, P. G. Davis, L. Wideman et al., “Effects of Tai American Family Physician, vol. 76, no. 4, pp. 549–556, 2007. Chi Chuan on insulin and cytokine levels in a randomized [117] G. Van der Watt, J. Laugharne, and A. Janca, “Complemen- controlled pilot study on breast cancer survivors.,” Clinical tary and alternative medicine in the treatment of anxiety and Breast Cancer, vol. 11, no. 3, pp. 161–170, 2011. depression,” Current Opinion in Psychiatry,vol.21,no.1,pp. [102] K. M. Mustian, J. A. Katula, D. L. Gill, J. A. Roscoe, D. Lang, 37–42, 2008. and K. Murphy, “Tai Chi Chuan, health-related quality of [118] A. Naing, S. K. Stephen, M. Frenkel et al., “Prevalence of life and self-esteem: a randomized trial with breast cancer complementary medicine use in a phase 1 clinical trials survivors,” Supportive Care in Cancer, vol. 12, no. 12, pp. 871– program: the MD Anderson cancer center experience,” 876, 2004. Cancer, vol. 117, no. 22, pp. 5142–5150, 2011. 12 Evidence-Based Complementary and Alternative Medicine

[119] F. Qi, A. Li, Y. Inagaki et al., “Chinese herbal medicines population,” Psychotherapy and Psychosomatics, vol. 72, no. as adjuvant treatment during chemo- or radio-therapy for 2, pp. 80–87, 2003. cancer,” Bioscience trends, vol. 4, no. 6, pp. 297–307, 2010. [138] M. W. P.Carney and B. F. Sheffield, “Serum folic acid and B12 [120] D. O. Kennedy, W. Little, C. F. Haskell, and A. B. Scholey, in 272 psychiatric in-patients,” Psychological Medicine, vol. 8, “Anxiolytic effects of a combination of Melissa officinalis no. 1, pp. 139–144, 1978. and Valeriana officinalis during laboratory induced stress,” [139] H. Tiemeier, H. Ruud van Tuijl, A. Hofman, J. Meijer, A. Phytotherapy Research, vol. 20, no. 2, pp. 96–102, 2006. J.Kiliaan,andM.M.B.Breteler,“VitaminB12,folate,and [121] S. F. Muller and S. Klement, “A combination of valerian and homocysteine in depression: the Rotterdam study,” American lemon balm is effective in the treatment of restlessness and Journal of Psychiatry, vol. 159, no. 12, pp. 2099–2101, 2002. dyssomnia in children,” Phytomedicine,vol.13,no.6,pp. [140] B. W. Penninx, J. M. Guralnik, L. Ferrucci, L. P. Fried, R. 383–387, 2006. H. Allen, and S. P. Stabler, “Vitamin B12 deficiency and [122] B. S. Weeks, “Formulations of dietary supplements and depression in physically disabled older women: epidemio- herbal extracts for relaxation and anxiolytic action: relarian,” logic evidence from the women’s health and aging study,” Medical Science Monitor, vol. 15, no. 11, pp. RA256–RA262, American Journal of Psychiatry, vol. 157, no. 5, pp. 715–721, 2009. 2000. [123] G. Mark, Herbal supplement for stress, http://www.livestrong [141] A. M. Hvas, S. Juul, P. Bech, and E. Nexø, “Vitamin B6 level is .com/article/15705-herbal-supplement-for-stress/ , 2010. associated with symptoms of depression,” Psychotherapy and [124] K. Soden, K. Vincent, S. Craske, C. Lucas, and S. Asley, “A Psychosomatics, vol. 73, no. 6, pp. 340–343, 2004. randomized controlled trial of aromatherapy massage in a [142] C. Merete, L. M. Falcon, and K. L. Tucker, “Vitamin B6 is hospice setting,” Palliative Medicine, vol. 18, no. 2, pp. 87–92, associated with depressive symptomatology in Massachusetts 2004. elders,” Journal of the American College of Nutrition, vol. 27, [125] D. Wheatley, “Kava and valerian in the treatment of stress- no. 3, pp. 421–427, 2008. induced insomnia,” Phytotherapy Research, vol. 15, no. 6, pp. [143] J. E. Alpert, D. Mischoulon, G. Rubenstein, K. Bottonari, A. 549–551, 2001. Nierenberg, and M. Fava, “Folinic acid (Leucovorin) as an [126] S. Akhondzadeh, H. R. Naghavi, M. Vazirian, A. Shayegan- adjunctive treatment for SSRI-refractory depression,” Annals pour, H. Rashidi, and M. Khani, “Passionflower in the of Clinical Psychiatry, vol. 14, no. 1, pp. 33–38, 2002. treatment of generalized anxiety: a pilot double-blind ran- [144] A. Coppen and J. Bailey, “Enhancement of the antidepressant domized controlled trial with oxazepam,” Journal of Clinical action of fluoxetine by folic acid: a randomised, placebo Pharmacy and Therapeutics, vol. 26, no. 5, pp. 363–367, 2001. controlled trial,” Journal of Affective Disorders,vol.60,no.2, [127] F. M. Painter, “Panax ginseng. Monograph,” Alternative pp. 121–130, 2000. Medicine Review, vol. 14, no. 2, pp. 172–176, 2009. [128] G. S. Kienle and H. Kiene, “Influence of viscum album L [145] P. S. A. Godfrey, B. K. Toone, M. W. P. Carney et (European Mistletoe) extracts on quality of life in cancer al., “Enhancement of recovery from psychiatric illness by patients: a systematic review of controlled clinical studies,” methylfolate,” The Lancet, vol. 336, no. 8712, pp. 392–395, Integrative Cancer Therapies, vol. 9, no. 2, pp. 142–157, 2010. 1990. [129] J. L. Reay, D. O. Kennedy, and A. B. Scholey, “Effects of Panax [146] E. Garcion, N. Wion-Barbot, C. N. Montero-Menei, F. ginseng, consumed with and without glucose, on blood Berger, and D. Wion, “New clues about vitamin D func- glucose levels and cognitive performance during sustained tions in the nervous system,” Trends in Endocrinology and ’mentally demanding’ tasks,” Journal of Psychopharmacology, Metabolism, vol. 13, no. 3, pp. 100–105, 2002. vol. 20, no. 6, pp. 771–781, 2006. [147] D. Eyles, J. Brown, A. Mackay-Sim, J. McGrath, and F. Feron, [130] S. Nechuta, W. Lu, Z. Chen et al., “Vitamin supplement use “Vitamin D3 and brain development,” Neuroscience, vol. 118, during breast cancer treatment and survival: a prospective no. 3, pp. 641–653, 2003. cohort study,” Cancer Epidemiology, Biomarkers & Prevention, [148] D. J. Armstrong, G. K. Meenagh, I. Bickle, A. S. H. Lee, vol. 20, no. 2, pp. 262–271, 2011. E. S. Curran, and M. B. Finch, “Vitamin D deficiency is [131] H. Greenlee, M.L. Kwan, L.H. Kushi et al., “Antioxidant associated with anxiety and depression in fibromyalgia,” supplement use after breast cancer diagnosis and mortality Clinical Rheumatology, vol. 26, no. 4, pp. 551–554, 2007. in the life after cancer epidemiology (LACE) cohort,” Cancer, [149] R. J. Przybelski and N. C. Binkley, “Is vitamin D important vol. 118, no. 8, pp. 2048–2058, 2012. for preserving cognition? A positive correlation of serum 25- [132] C. M. Velicer and C. M. Ulrich, “Vitamin and mineral hydroxyvitamin D concentration with cognitive function,” supplement use among US adults after cancer diagnosis: a Archives of Biochemistry and Biophysics, vol. 460, no. 2, pp. systematic review,” Journal of Clinical Oncology, vol. 26, no. 202–205, 2007. 4, pp. 665–673, 2008. [150] C. H. Wilkins, Y. I. Sheline, C. M. Roe, S. J. Birge, and J. C. [133] C. Van Guldener and C. D. A. Stehouwer, “Homocysteine- Morris, “Vitamin D deficiency is associated with low mood lowering treatment: an overview,” Expert Opinion on Phar- and worse cognitive performance in older adults,” American macotherapy, vol. 2, no. 9, pp. 1449–1460, 2001. Journal of Geriatric Psychiatry, vol. 14, no. 12, pp. 1032–1040, [134] O. P. Almeida, K. McCaul, G. J. Hankey, P. Norman, K. 2006. Jamrozik, and L. Flicker, “Homocysteine and depression in [151] R. Jorde, M. Sneve, Y. Figenschau, J. Svartberg, and K. Water- later life,” Archives of General Psychiatry, vol. 65, no. 11, pp. loo, “Effects of vitamin D supplementation on symptoms 1286–1294, 2008. of depression in overweight and obese subjects: randomized [135] M. W. P. Carney, T. K. N. Chary, M. Laundy et al., “Red double blind trial,” Journal of Internal Medicine, vol. 264, no. cell folate concentrations in psychiatric patients,” Journal of ff 6, pp. 599–609, 2008. A ective Disorders, vol. 19, no. 3, pp. 207–213, 1990. [152] D. Schlager, J. E. Schwartz, and E. J. Bromet, “Seasonal [136] M. T. Coppen and A. Abou-Saleh, “Plasma folate and variations of current symptoms in a healthy population,” affective morbidity during long-term lithium therapy,” The British Journal of Psychiatry, vol. 163, pp. 322–326, 1993. British Journal of Psychiatry, vol. 141, pp. 87–89, 1982. [137] M. S. Morris, M. Fava, P. F. Jacques, J. Selhub, and I. [153] F. M. Gloth, W. Alam, and B. Hollis, “Vitamin D vs H. Rosenberg, “Depression and folate status in the US broad spectrum phototherapy in the treatment of Seasonal Evidence-Based Complementary and Alternative Medicine 13

Affective Disorder,” Journal of Nutrition, Health and Aging, trial,” Journal of Alternative and Complementary Medicine, vol. 3, no. 1, pp. 5–7, 1999. vol. 9, no. 1, pp. 77–89, 2003. [154] A. T. Lansdowne and S. C. Provost, “Vitamin D3 enhances [168] J. A. Roscoe, S. E. Matteson, K. M. Mustian, D. Padmanaban, mood in healthy subjects during winter,” Psychopharmacol- and G. R. Morrow, “Treatment of radiotherapy-induced ogy, vol. 135, no. 4, pp. 319–323, 1998. fatigue through a nonpharmacological approach,” Integrative [155] S. C. Gupta, J. H. Kim, R. Kannappan, S. Reuter, P. M. Cancer Therapies, vol. 4, no. 1, pp. 8–13, 2005. Dougherty, and B. B. Aggarwal, “Role of nuclear factor- [169] K. M. Mustian, J. A. Roscoe, O. G. Palesh et al., “Polarity kappaB-mediated inflammatory pathways in cancer-related therapy for cancer-related fatigue in patients with breast symptoms and their regulation by nutritional agents,” Exper- cancer receiving radiation therapy: a randomized controlled imental Biology and Medicine, vol. 236, no. 6, pp. 658–671, pilot study,” Integrative Cancer Therapies, vol. 10, no. 1, pp. 2011. 27–37, 2011. [156] R. Koto, M. Imamura, C. Watanabe et al., “Linalyl acetate as [170] L. Korn, R. G. Logsdon, N. L. Polissar, A. Gomez-Beloz, T. a major ingredient of lavender essential oil relaxes the rab- Waters, and R. Ryser,¨ “A randomized trial of a cam therapy bit vascular smooth muscle through dephosphorylation of for stress reduction in American Indian and Alaskan native myosin light chain,” Journal of Cardiovascular Pharmacology, family caregivers,” Gerontologist, vol. 49, no. 3, pp. 368–377, vol. 48, no. 1, pp. 850–856, 2006. 2009. [157] J. Drozd and E. Anuszewska, “The effect of the Melissa [171] K. Olson, J. Hanson, and M. Michaud, “A phase II trial officinalis extract on immune response in mice,” Acta of Reiki for the management of pain in advanced cancer Poloniae Pharmaceutica, vol. 60, no. 6, pp. 467–470, 2003. patients,” Journal of Pain and Symptom Management, vol. 26, [158] D. Ivanova, D. Gerova, T. Chervenkov, and T. Yankova, no. 5, pp. 990–997, 2003. “Polyphenols and antioxidant capacity of Bulgarian medic- [172] K. L. Tsang, L. E. Carlson, and K. Olson, “Pilot crossover inal plants,” Journal of Ethnopharmacology, vol. 96, no. 1-2, trial of Reiki versus rest for treating cancer-related fatigue,” pp. 145–150, 2005. Integrative Cancer Therapies, vol. 6, no. 1, pp. 25–35, 2007. [159] B. Marongiu, S. Porcedda, A. Piras, A. Rosa, M. Deiana, and [173] S. B. Hanser, S. Bauer-Wu, L. Kubicek et al., “Effects of a M. A. Dess´ı, “Antioxidant activity of supercritical extract of music therapy intervention on quality of life and distress in Melissa officinalis subsp. officinalis and Melissa officinalis women with metastatic breast cancer,” Journal of the Society subsp. inodora,” Phytotherapy Research, vol. 18, no. 10, pp. for Integrative Oncology, vol. 4, no. 3, pp. 116–124, 2006. 789–792, 2004. [174] D. S. Burns, F. Azzouz, R. Sledge et al., “Music imagery for [160] V. Butterweck, “Mechanism of action of St John’s wort in adults with acute leukemia in protective environments: a depression: what is known?” CNS Drugs,vol.17,no.8,pp. feasibility study,” Supportive Care in Cancer, vol. 16, no. 5, 539–562, 2003. pp. 507–513, 2008. [161] D. Benke, A. Barberis, S. Kopp et al., “GABAA receptors as [175] P. Salmon, “Effects of physical exercise on anxiety, depres- in vivo substrate for the anxiolytic action of valerenic acid, sion, and sensitivity to stress: a unifying theory,” Clinical a major constituent of valerian root extracts,” Neuropharma- Psychology Review, vol. 21, no. 1, pp. 33–61, 2001. cology, vol. 56, no. 1, pp. 174–181, 2009. [176] A. Tsatsoulis and S. Fountoulakis, “The protective role of [162] S. M. Elsas, D. J. Rossi, J. Raber et al., “Passiflora incarnata L. exercise on stress system dysregulation and comorbidities,” (Passionflower) extracts elicit GABA currents in hippocam- Annals of the New York Academy of Sciences, vol. 1083, pp. pal neurons in vitro, and show anxiogenic and anticon- 196–213, 2006. ff vulsant e ects in vivo, varying with extraction method,” [177] J. Midtgaard, M. Rørth, R. Stelter et al., “The impact of a Phytomedicine, vol. 17, no. 12, pp. 940–949, 2010. multidimensional exercise program on self-reported anxiety [163] P. Hegde, M.S. Maddur, A. Friboulet, J. Bayry, and S.V. and depression in cancer patients undergoing chemotherapy: Kaveri, “Viscum album exerts anti-inflammatory effect a phase II study,” Palliative & Supportive Care,vol.3,no.3, by selectively inhibiting cytokine-induced expression of pp. 197–208, 2005. cyclooxygenase-2,” PLoS ONE, vol. 6, no. 10, Article ID [178] C. Y. Yang, J. C. Tsai, Y. C. Huang, and C. C. Lin, “Effects of e26312, 2011. ahome-basedwalkingprogramonperceivedsymptomand [164] A. Billhult, C. Lindholm, R. Gunnarsson, and E. Stener- mood status in postoperative breast cancer women receiving Victorin, “The effect of massage on immune function adjuvant chemotherapy,” Journal of Advanced Nursing, vol. and stress in women with breast cancer—a randomized 67, no. 1, pp. 158–168, 2011. controlled trial,” Autonomic Neuroscience, vol. 150, no. 1-2, [179] L. A. Faul, H. S. Jim, S. Minton, M. Fishman, T. Tanvetyanon, pp. 111–115, 2009. and P. B. Jacobsen, “Relationship of exercise to quality of life [165] M. Listing, M. Krohn, C. Liezmann et al., “The efficacy of in cancer patients beginning chemotherapy,” Journal of Pain classical massage on stress perception and cortisol following and Symptom Management, vol. 41, no. 5, pp. 859–869, 2011. primary treatment of breast cancer,” Archives of Women’s [180] V. Mock, K. H. Dow, C. J. Meares et al., “Effects of exercise Mental Health, vol. 13, no. 2, pp. 165–173, 2010. on fatigue, physical functioning, and emotional distress [166] A. Moraska, R. A. Pollini, K. Boulanger, M. Z. Brooks, and during radiation therapy for breast cancer,” Oncology Nursing L. Teitlebaum, “Physiological adjustments to stress measures Forum, vol. 24, no. 6, pp. 991–1000, 1997. following massage therapy: a review of the literature,” Evid [181] S. K. Chambers, B. M. Lynch, J. Aitken, and P. Baade, Based Complement Alternat Med, vol. 7, no. 4, pp. 409–418, “Relationship over time between psychological distress and 2010. physical activity in colorectal cancer survivors,” Journal of [167] A. G. Taylor, D. I. Galper, P. Taylor et al., “Effects of Clinical Oncology, vol. 27, no. 10, pp. 1600–1606, 2009. adjunctive Swedish massage and vibration therapy on short- [182] F. L. Bishop, P.Prescott, Y. K. Chan, J. Saville, E. Von Elm, and term postoperative outcomes: a randomized, controlled G. T. Lewith, “Prevalence of complementary medicine use in 14 Evidence-Based Complementary and Alternative Medicine

pediatric cancer: a systematic review,” Pediatrics, vol. 125, no. with elderly-onset rheumatoid arthritis: a comparison with 4, pp. 768–776, 2010. younger-onset disease,” Gerontology, vol. 55, no. 3, pp. 250– [183] J. Post-White, M. Fitzgerald, S. Hageness, and S. F. Sencer, 258, 2009. “Complementary and alternative medicine use in children [199] T. T. Suh and K. W. Lyles, “Osteoporosis considerations in the with cancer and general and specialty pediatrics,” Journal of frail elderly,” Current Opinion in Rheumatology, vol. 15, no. 4, Pediatric Oncology Nursing, vol. 26, no. 1, pp. 7–15, 2009. pp. 481–486, 2003. [184] I. Nathanson, E. Sandler, G. Ram´ırez-Garnica, and S. A. [200] A. Russo, M. Cesari, G. Onder et al., “Depression and Wiltrout, “Factors influencing complementary and alterna- physical function: results from the aging and longevity study tive medicine use in a multisite pediatric oncology practice,” in the Sirente geographic area (ilSIRENTE study),” Journal of Journal of Pediatric Hematology/Oncology, vol. 29, no. 10, pp. Geriatric Psychiatry and Neurology, vol. 20, no. 3, pp. 131– 705–708, 2007. 137, 2007. [185] D. Tomlinson, T. Hesser, M.-C. Ethier, and L. Sung, “Com- [201] A. Thalmann, M. Morfeld, and A. Benthien, “Anxiety and plementary and alternative medicine use in pediatric cancer depression in the elderly-results of a regional examination,” reported during palliative phase of disease,” Supportive Care Gesundheitswesen, vol. 74, no. 1, pp. 29–33, 2010. in Cancer, vol. 19, no. 11, pp. 1857–1863, 2011. [202] G. Dal Forno and C. H. Kawas, “Cognitive problems in the [186] M. A. Grootenhuis, B. F. Last, J. H. De Graaf-Nijkerk, and elderly,” Current Opinion in Neurology, vol. 8, no. 4, pp. 256– M. Van Der Wel, “Use of alternative treatment in pediatric 261, 1995. oncology,” Cancer Nursing, vol. 21, no. 4, pp. 282–288, 1998. [203] S. G. Mohile, Y. Xian, W. Dale et al., “Association of a cancer [187] S. F. Sencer and K. M. Kelly, “Complementary and alternative diagnosis with vulnerability and frailty in older medicare therapies in pediatric oncology,” Pediatric Clinics of North beneficiaries,” Journal of the National Cancer Institute, vol. America, vol. 54, no. 6, pp. 1043–1060, 2007. 101, no. 17, pp. 1206–1215, 2009. [188] K. M. Kelly, “Complementary and alternative medical ther- [204] F. Baker, S. C. Haffer, and M. Denniston, “Health-related apies for children with cancer,” European Journal of Cancer, quality of life of cancer and noncancer patients in medicare vol. 40, no. 14, pp. 2041–2046, 2004. managed care,” Cancer, vol. 97, no. 3, pp. 674–681, 2003. [189] E. J. Ladas, D. J. Kroll, N. H. Oberlies et al., “A randomized, [205] A. M. Washburn, “Relocation puts elderly nursing home controlled, double-blind, pilot study of milk thistle for the residents at risk of stress, although the stress is short lived: treatment of hepatotoxicity in childhood Acute Lymphoblas- commentary,” Evidence-Based Mental Health,vol.8,no.2,p. tic Leukemia (ALL),” Cancer, vol. 116, no. 2, pp. 506–513, 49, 2005. 2010. [190] S. Phipps, M. Barrera, K. Vannatta, X. Xiong, J. J. Doyle, [206] L. N. Grinstead, S. Leder, S. Jensen, and L. Bond, “Review of and M. A. Alderfer, “Complementary therapies for children research on the health of caregiving grandparents,” Journal of undergoing stem cell transplantation: report of a multisite Advanced Nursing, vol. 44, no. 3, pp. 318–326, 2003. trial,” Cancer, vol. 116, no. 16, pp. 3924–3933, 2010. [207] M. P. Jendrek, “Grandparents who parent their grandchil- [191] R. Hawks, “Complementary and alternative medicine dren: circumstances and decisions,” Gerontologist, vol. 34, no. research initiatives in the Children’s Oncology Group and 2, pp. 206–216, 1994. the role of the pediatric oncology nurse,” Journal of Pediatric [208] M. Minkler and E. Fuller-Thomson, “The health of grand- Oncology Nursing, vol. 23, no. 5, pp. 261–264, 2006. parents raising grandchildren: results of a national study,” [192] K. M. Kelly, “Bringing evidence to complementary and American Journal of Public Health, vol. 89, no. 9, pp. 1384– alternative medicine in children with cancer: focus on 1389, 1999. nutrition-related therapies,” Pediatric Blood and Cancer, vol. [209] P. S. Lee, Y. M. Lee, J. Y. Lim, R. I. Hwang, and E. Y. Park, 50, no. 2, pp. 490–493, 2008. “The relationship of stress, social support and depression in [193] J. N. Haun, J. Graham-Pole, and B. Shortley, “Children with the elderly,” Taehan Kanho Hakhoe chi, vol. 34, no. 3, pp. 477– cancer and blood diseases experience positive physical and 484, 2004. psychological effects from massage therapy,” International [210] J. Moller,¨ J. Hallqvist, L. Laflamme et al., “Emotional stress as Journal of Therapeutic Massage & Bodywork,vol.2,no.2,p. a trigger of falls leading to hip or pelvic fracture. Results from 7, 2009. the ToFa study-a case-crossover study among elderly people [194] D. S. Burns, S. L. Robb, and J. E. Haase, “Exploring the in Stockholm, Sweden,” BMC Geriatrics,vol.9,no.1,p.7, feasibility of a therapeutic music video intervention in ado- 2009. lescents and young adults during stem-cell transplantation,” [211] J. B. Unger, C. A. Johnson, and G. Marks, “Functional Cancer Nursing, vol. 32, no. 5, pp. E8–E16, 2009. decline in the elderly: evidence for direct and stress- buffering [195] R. J. Barnard, G. K. Grimditch, and J. H. Wilmore, “Phys- protective effects of social interactions and physical activity,” iological characteristics of sprint and endurance Masters Annals of Behavioral Medicine, vol. 19, no. 2, pp. 152–160, runners,” Medicine and Science in Sports and Exercise, vol. 11, 1997. no. 2, pp. 167–171, 1979. [212] W. J. Chodzko-Zajko, N. David, A. Maria et al., “American [196] S. A. Hawkins and R. A. Wiswell, “Rate and mechanism of college of sports medicine position stand. Exercise and maximal oxygen consumption decline with aging: implica- physical activity for older adults,” Medicine & Science in tions for exercise training,” Sports Medicine, vol. 33, no. 12, Sports & Exercise, vol. 41, no. 7, pp. 1510–1530, 2009. pp. 877–888, 2003. [213] M. E. Nelson, W. J. Rejeski, S. N. Blair et al., “Physical [197] H. K. Kamel, “Sarcopenia and aging,” Nutrition Reviews, vol. activity and public health in older adults: recommendation 61, no. 5, part 1, pp. 157–167, 2003. from the American College of Sports Medicine and the [198] D. Y. Chen, T. Y. Hsieh, Y. M. Chen, C. W. Hsieh, J. L. Lan, American Heart Association,” Medicine and Science in Sports and F. J. Lin, “Proinflammatory cytokine profiles of patients and Exercise, vol. 39, no. 8, pp. 1435–1445, 2007. Evidence-Based Complementary and Alternative Medicine 15

[214] H. Lavretsky, L. L. Alstein, R. E. Olmstead et al., “Comple- mentary use of tai chi chih augments escitalopram treatment of geriatric depression: a randomized controlled trial,” The American Journal of Geriatric Psychiatry, vol. 19, no. 10, pp. 839–850, 2011. [215] F. Li, P. Harmer, E. McAuley, K. J. Fisher, T. E. Duncan, and S. C. Duncan, “Tai Chi, self-efficacy, and physical function in the elderly,” Prevention Science, vol. 2, no. 4, pp. 229–239, 2001. [216] C. Lan, J. S. Lai, S. Y. Chen, and M. K. Wong, “Tai Chi Chuan to improve muscular strength and endurance in elderly individuals: a pilot study,” Archives of Physical Medicine and Rehabilitation, vol. 81, no. 5, pp. 604–607, 2000. [217] D. P. K. Leung, C. K. Chan, H. W. Tsang, W. W. Tsang, and A. Y. Jones, “Tai chi as an intervention to improve balance and reduce falls in older adults: a systematic and meta-analytical review,” Alternative Therapies in Health and Medicine, vol. 17, no. 1, pp. 40–48, 2011. [218] M. DiBenedetto, K. E. Innes, A. G. Taylor et al., “Effect of a gentle iyengar yoga program on gait in the elderly: an exploratory study,” Archives of Physical Medicine and Rehabilitation, vol. 86, no. 9, pp. 1830–1837, 2005. [219] L. C. Gonc¸alves,R.G.D.S.Vale,N.J.F.Barata,R.V.Varejao,˜ and E. H. M. Dantas, “Flexibility, functional autonomy and quality of life (QoL) in elderly yoga practitioners,” Archives of Gerontology and Geriatrics, vol. 53, no. 2, pp. 158–162, 2011. [220] M. Shahidi, A. Mojtahed, A. Modabbernia et al., “Laughter yoga versus group exercise program in elderly depressed women: a randomized controlled trial,” International Journal of Geriatric Psychiatry, vol. 26, no. 3, pp. 322–327, 2011. Copyright of Evidence-based Complementary & Alternative Medicine (eCAM) is the property of Hindawi Publishing Corporation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.